Lund O, Christensen J, Holme S, Fruergaard K, Olesen A, Kassis E, Abildgaard U
Department of Cardio-thoracic Surgery, Copenhagen University Hospital in Gentofte, Copenhagen, Denmark.
Eur J Cardiothorac Surg. 2001 Nov;20(5):901-7. doi: 10.1016/s1010-7940(01)00972-1.
Current knowledge on off-pump coronary artery bypass (OPCAB) generally stems from single surgeons' experience or from series where OPCABs constituted a minor fraction of coronary operations. The present center decided to venture as far into OPCAB as possible during 1999. The present series thus represents the average surgeon's experience.
During 1999, 533 patients underwent coronary artery bypass grafting using cardiopulmonary bypass (CPB) in 368 and OPCAB in 165 including the circumflex artery (CX) area in 91. Coronary arteriography was performed before discharge in the first 103 OPCAB patients.
The CPB and OPCAB groups differed as regards left ventricular ejection fraction (53+/-13 versus 57+/-11, P < 0.0001) and frequency of triple-vessel or left main stem disease (84 versus 32%, P < 0.0001) but were comparable as regards diabetes (12%), prior myocardial infarct (57%), unstable angina (21%), and previous heart surgery (3%). Using multivariate analyses, 30-day mortality (1.3%), P-creatine kinase myocardial band (CKMB) > 80 microg/l (11.1%), re-sternotomy for bleeding (4.5%) or dehiscense (1.7%), transitory cerebral ischemia and stroke (1.7%), supraventricular tachycardia (27.4%), and hospital stay (mean 8 days) were unrelated to off- versus on-pump surgery as well as to OPCAB in triple-vessel disease. CX branches < or = 1mm, > or = 5 distal anastomoses, prior heart surgery, right coronary artery (RCA) branches < or = 1.5mm, 8-21 days old myocardial infarct, female gender, and preoperative acute arrhythmia (among others) were identified as independent risk factors for mortality or increased CKMB in all 533 patients. The latter five risk factors were reproduced in the OPCAB group isolated. The patency in the 103 OPCABs was 95.3, 91.8, and 85.3% in the left anterior descending artery (LAD), CX, and RCA, respectively. Patency was inversely related to diameter of the grafted vessel in the LAD and CX areas, unlike the RCA area.
The results after beating heart surgery were good also in patients with triple-vessel disease, but specific gains relative to on-pump surgery could not be shown. The independent risk factors in the OPCAB group may indicate relative contraindications for OPCAB grafting.
目前关于非体外循环冠状动脉搭桥术（OPCAB）的知识通常源于个别外科医生的经验，或者源于OPCAB在冠状动脉手术中占比小的系列研究。本中心决定在1999年尽可能多地开展OPCAB手术。因此，本系列研究代表了普通外科医生的经验。
1999年期间，533例患者接受了冠状动脉搭桥术，其中368例使用体外循环（CPB），165例接受OPCAB，包括91例涉及回旋支（CX）区域的手术。对前103例OPCAB患者在出院前进行了冠状动脉造影。
CPB组和OPCAB组在左心室射血分数方面存在差异（分别为53±13和57±11，P<0.0001），以及三支血管病变或左主干病变的发生率方面存在差异（分别为84%和32%，P<0.0001），但在糖尿病（12%）、既往心肌梗死（57%）、不稳定型心绞痛（21%）和既往心脏手术史（3%）方面具有可比性。使用多因素分析，30天死亡率（1.3%）、肌酸激酶心肌同工酶（CKMB）>80μg/L（11.1%）、因出血（4.5%）或切口裂开（1.7%）再次开胸、短暂性脑缺血和中风（1.7%）、室上性心动过速（27.4%）以及住院时间（平均8天）与非体外循环手术和体外循环手术无关，也与三支血管病变患者的OPCAB无关。CX分支≤1mm、≥5个远端吻合口、既往心脏手术史、右冠状动脉（RCA）分支≤1.5mm、8 - 21天的心肌梗死、女性以及术前急性心律失常（等等）被确定为所有533例患者死亡或CKMB升高的独立危险因素。后五个危险因素在单独的OPCAB组中也有体现。103例OPCAB患者中，左前降支（LAD）、CX和RCA的通畅率分别为95.3%、91.8%和85.3%。与RCA区域不同，LAD和CX区域的通畅率与移植血管直径呈负相关。
对于三支血管病变患者，心脏跳动手术的结果也较好，但相对于体外循环手术而言，未显示出特定的优势。OPCAB组中的独立危险因素可能提示OPCAB移植的相对禁忌证。
